TREATMENT OF PAIN

The objective of pain treatment is to remove or correct the cause of pain or to lessen the severity of the pain; however, there can be a lag in time between identifying the cause of the pain and providing relief. The treatment of pain is diverse and can be difficult. A multidisciplinary approach to chronic pain management is often most successful but is not always available to everyone. This team approach involves both medical and nonmedical personnel and may include any of a number of approaches. There also are a number of integrative/complementary pain control protocols that may be effective. Treatment of pain depends on the type of pain. Medications, also, are different in their pain control management.

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Medications

Medications tend to be the treatment of choice for many clients experiencing pain. Analgesics, anesthetics, and anti-inflammatory agents may be prescribed to decrease or eliminate pain, although they do not eliminate the cause of pain. Analgesics can be opioid (formerly referred to as narcotic) or nonopioid (formerly referred to as nonnarcotic), prescription or over-the-counter (OTC), and of varying strengths. Opioid analgesics may include morphine-like drugs, whereas nonopioid drugs include acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs). A third category of drugs called adjuvant analgesics include those whose primary purpose is not generally used or prescribed for pain. For example, drugs used for depression may be prescribed to effectively treat pain. Other adjuvant medications include those used for seizure control and corticosteroids. Medication may be administered orally, intravenously, nasally, by injection, or from a skin patch. Additionally, medications may be used alone or in conjunction with other treatment modalities.

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Nonprescription Drug Therapy

OTC medications may be useful in relieving milder forms of pain. These medications include acetaminophen (Tylenol) or such NSAIDs as aspirin, Aleve, or Advil. Both acetaminophen and NSAIDs can relieve pain due to muscle aches, but NSAIDs also are able to reduce inflammation. There are a number of creams and salves on the market that can reduce pain. These topical analgesics likely give a “warm” sensation when applied to the area. Capzasin is known to give a “hot” feeling to the skin, and some have found it beneficial in the treatment of arthritic pain.

Nonprescription medications are taken so readily and freely by members of society that warning labels are often ignored. Those warnings, however, are quite important. Gastroenterologists advise all their clients that acetaminophen and NSAIDs can have an adverse effect on the digestive system. The second major cause of ulcers is the overuse of NSAIDs. Long-term use of these medications should be monitored by a primary care provider who can help weigh the benefits of the drug treatment against possible side effects.

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Prescription Drug Therapy

Prescription drug therapy may include muscle relaxants, antianxiety medications, antidepressants, prescription NSAIDs, steroids, and opioids. Muscle relaxants have an overall sedative effect on the body and act on the brain rather than the muscles to create a total body relaxant. They can be beneficial for muscle spasms and early treatment of low-back pain and can aid in sleep when pain keeps individuals awake. Side effects should be carefully considered. They can be habit-forming and may create changes in sleep cycles.

Antianxiety and antidepressant medications help to reduce depression and anxiety, but some also are able to reduce pain in muscles and joints. They can be particularly helpful for migraine headaches and neuropathic pain. These medications are powerful central nervous system depressants that may be used alone or in conjunction with other analgesic medications.

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Prescription NSAIDs reduce inflammation and pain when they block enzymes and prostaglandins (proteins) made by the body. Prostaglandins cause pain when they irritate nerve endings. Prostaglandins help to protect the stomach lining, so blocking this enzyme may produce an adverse effect. These drugs do not alter a person’s cognitive functioning, cause respiratory depression, or cause nausea. A common NSAID is Celebrex, which carries the additional warning of risk for heart attack and stroke. Steroids are very potent anti-inflammatory drugs that also reduce pain. Steroids work directly on the brain’s chemistry to elevate mood and reduce pain.

Steroids, unfortunately, have possible side effects. They suppress the body’s immune function, cause fluid retention and weight gain, can worsen diabetes, and can reduce bone density when used for long periods of time.

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Epidural steroid injections are very useful in alleviating pain that radiates from the lower back into the leg (as seen in spinal stenosis [ICD-9: 724.00]) or neck pain that radiates into the arm. The physician uses x-ray fluoroscopy to guide the needle directly into the neural foramen or the point where the affected nerve root exits the spinal canal. These injections do not have the side effects attributed to oral steroids.

Opioids are strong and potentially addictive; therefore, they are to be carefully monitored by the provider giving the prescription. While opioids do not actually rid a person of pain, they work to separate or distance individuals from the feeling of pain. Common opioids are codeine, hydrocodone, oxycodone, and morphine. They are effective pain relievers for all types of pain. There are, however, side effects to consider. They include impairment of mental function, constipation, possible addiction, and interaction with acetaminophen.

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Research indicates that health-care professionals and family members tend to undermedicate for pain because of incorrect assumptions, prevailing attitudes, the complexity of pain assessment, and unfounded fears, mainly those of addiction (psychological dependence). However, no medical research testifies to such an addiction. In fact, the use of opioids is indicated in many cases of pain management, and evidence is overwhelming that such fears are greatly exaggerated. Untreated pain adversely affects pulmonary, gastrointestinal, and circulatory systems and can cause insomnia, depression, and irritability, if the pain becomes chronic. Pain must be reduced for healing to occur.

Patient-Controlled Analgesia Pump

Portable infusion pump

FIGURE. Portable infusion pump (CADD-Legacy PCA) for patient-controlled analgesia (PCA). (Courtesy of Smiths Medical MD, Inc., St. Paul, Minnesota, with permission.)

A common treatment of some pain is the patientcontrolled analgesia (PCA) pump. The pump allows clients to administer their own pain medication, offering some sense of control of the pain, which is an important psychological benefit. In PCA, the amount of drug dispensed by the pump is determined by the primary care provider. The device is designed to not release more than the prescribed amount within a set period of time, thus guarding against overmedication. Clients who should not use a PCA are those with hypersensitivity to the medication used, those with physical impairments that make it difficult to activate the pump, and those with any emotional or cognitive disability.

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Intrathecal Drug Delivery

This method to control pain is similar to the PCA pump except that a surgeon places a medicine pump in a small pocket under the skin that delivers medicine from the pump to the intrathecal space around the spinal cord. This system can provide significant pain control with far less drugs than required with pills.

Surgery

Surgery may be necessary to block the transmission of pain or to remove the cause of pain. Surgery for relief of pain may include such procedures as neurotomy or dissection or division of a nerve; cordotomy or surgical division of one or more of the lateral nerve pathways emerging from the spinal cord; and hypophysectomy or removal of the pituitary gland, as well as the removal of any causative factor. Surgery may be helpful to relieve the pain of pancreatic cancer, the severe intractable pain from other malignancies, or intractable abdominal pain.

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Placebos

An interesting phenomenon is the use of placebos in pain management. A placebo is defined as a medication that produces an effect in a client because of its intent rather than because of its specific physical or chemical properties. In the placebo effect, the person is given a medication or treatment because the person believes it to be effective. When such placebos are used, studies show that 20% to 40% of those with objective stimuli report pain relief, at least for a short time. This is a powerful example of the mind-body connection. The placebo effect results from the natural production of endorphins and enkephalins in the descending control system. The more cues the client receives about the placebo’s effectiveness, the more likely it will be effective in relieving pain.

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Back pain. The Cause of Pain THE NOCICEPTIVE RECEPTOR SYSTEM Most tissues in the body possess a system of nerve endings which, being particularly sensitive to tissue dysfunction, may be referred to as nociceptive receptors. The free nerve endings of the nociceptive system provide the means by which we are made aware of pain. Wyke describes the distribution of the nociceptive receptor system in the lumbar area: it is found in the skin and subcutaneous tissue; throughout the fibrous capsule of all the synovial apophyseal joints and sacro-iliac joints; in the longitudinal ligaments, the fiaval and interspinous ligaments and sacro-iliac ligaments; in the periosteum covering the vertebral bodies and arches, and in the fascia, aponeuroses and tendons attached thereto; and also in the spinal dura mater, including the dural sleeves surrounding the nerve roots. The nociceptive innervation of the spinal ligaments varies from one ligament to another. The system is found to be most dense in the posterior longitudinal l...
Spine Health. PROCEDURE 14 — FLEXION IN STANDING The simple toe touching exercise in standing does not need much elaboration. The patient, standing with the feet about thirty centimeters apart, bends forward sliding the hands down the front of the legs in order to have some support and to measure the degree of flexion achieved. On reaching the maximum flexion allowed by pain or range, the patient returns to the upright position. The sequence is repeated about ten times, should be performed rhythmically, and initially with caution and without vigour. It is important to ensure that in between each movement the patient returns to neutral standing. Fig. Flexion in standing. Effects: Flexion in standing differs from flexion in lying in various ways. Naturally, the gravitational and compressive forces act differently in both situations. In flexion in standing the movement takes place from above downwards, and the lower lumbar and lumbo-sacral joints are placed on full stretch only at the end of the movement. In addition, the lumbo...
Spine Health. PROCEDURE 12 — ROTATION MANIPULATION IN FLEXION The sequence of procedure 11 must be followed completely to perform the required pre-manipulative testing. If the manipulation is indicated a sudden thrust of high velocity and small amplitude is performed, moving the spine into extreme side bending and rotation. Fig. Rotation manipulation in flexion. Effects: There are many techniques devised for rotation manipulation of the lumbar spine. When rotation of the lumbar spine is achieved by using the legs of the patient as a lever or fulcrum of movement, confusion arises as to the direction in which the lumbar spine rotates. This is judged by the movement of the upper vertebrae in relation to the lower — for example, if the patient is lying supine and the legs are taken to the right, then the lumbar spine rotates to the left. It has become widely accepted that rotation manipulation of the spine should be performed by rotation away from the painful side. This has applied to derangement as well as dysfunction, because hitherto n...
ASSESSMENT OF PAIN Pain gives the body warning and often is accompanied by anxiety and the need to relieve the pain. Pain is both sensation and emotion. As noted earlier, it can be acute or chronic. Health-care professionals may find the following mnemonic tool useful for assessing a client in pain: P = place (client points with one finger to the location of the pain) A = amount (client rates pain on a scale from 0 to 10 ) I = interactions (client describes what worsens the pain) N = neutralizers (client describes what lessens the pain) The scale of 0 to 10, as described in the mnemonic, is a useful method of assessing pain. Further pain assessment skills include observing the client’s appearance and activity. Monitoring the client’s vital signs may be of value in assessing acute pain but not necessarily chronic pain. To assess the pain of children or those with some cognitive dysfunction or dementia, a “smiley face” model often proves beneficial. The first smiley face shows a happy face...
GATE CONTROL THEORY OF PAIN What occurs at the cellular level when pain is experienced? The gate control theory of pain, by P. D. Wall and Ronald Melzack, offers a useful model of the physiological process of pain. Gate control is recognized as a major pain theory. According to the gate control theory, pain is a balance between information traveling into the spinal cord through large nerve fibers and information traveling into the spinal cord through small nerve fibers. Without any stimulation, both the large and small nerve fibers are quiet, and the substantia gelatinosa (SG) blocks the signal to the transmission cell (T cell) connected to the brain. The “gate is closed,” and there is no pain. With pain stimulation, small nerve fibers are active. They activate the T-cell neurons but block the SG neuron, making it impossible for the SG to block the T-cell transmission to the brain. The result is that the “gate is open”; therefore, there is pain. In other words, pain is experienced whenever the substances that ...